Case 200801882 - Cwm Taf NHS Trust

Summary

Mrs D complained that there were excessive delays in diagnosing her husband’s cancer, despite the fact he had reported symptoms for a number of years. She was also concerned that her husband was not offered adequate pain relief. Sadly, Mr D passed away during the course of the Ombudsman’s investigation.

The Ombudsman found that initial investigations into Mr D’s ear pain carried out at Prince Charles Hospital in Merthyr Tydfil in 2006 were reasonable; relevant tests and examinations were done, and nothing abnormal was found. It was therefore entirely reasonable that Mr D was referred back to the care of his GP.

Mr D’s GP referred him back to Prince Charles Hospital in April 2007 as he had now developed a hoarse voice in addition to the ear pain. Mr D was seen in the Ear, Nose and Throat Department by a Staff Grade Doctor in May 2007 and was referred for a CT scan of relevant areas. The CT scan did not take place until November 2007; and it was a further three weeks before the scan was reported on. The scan showed signs suggestive of cancer. The Ombudsman found that given the symptoms reported by Mr D in May 2007, he should have been referred for an urgent CT scan. The referral form for the CT scan had not been entered on the Trust’s computer system and had subsequently been destroyed. It was therefore impossible to say whether the Staff Grade Doctor had failed to mark the referral as “urgent”, or whether there was a clerical error in the radiology department which led to the referral being incorrectly categorised as “routine” on the computer system. The effect of this was that Mr D had to wait six months for a scan which should have been done within 2 – 3 weeks.

Once the CT scan had been reported in December 2007, Mr D underwent a number of diagnostic tests at Prince Charles Hospital. It was not until April 2008 that his diagnosis was confirmed (albeit not all the delays in this period were within the Trust’s control). The Ombudsman found that the management of the investigations between December 2007 and April 2008 was somewhat chaotic; had a lymph node biopsy been done at the outset, it is likely that the diagnosis would have been arrived at sooner and saved Mr D the trouble of having to undergo most of the other investigations, some of which he found uncomfortable.

The Ombudsman was unable to say whether or not Mr D’s prognosis would have been different had the cancer been diagnosed sooner; however, he upheld the complaint that there had been unreasonable delay. Mr D should have received an urgent scan, but this did not happen. Once the scan had been done, the subsequent investigations should have been done in a more coherent and targeted way. The consequence for Mr D was that he had to wait 11 months for the diagnosis following his ENT appointment in May 2007; during which time he was in pain. The Ombudsman partially upheld the complaint about inadequate pain relief as it is very difficult to adequately manage a person’s pain until the cause is known.

The Ombudsman was pleased to note that the then Trust had already accepted some failings and apologised to Mr and Mrs D. It had also made significant improvements to the radiology department at Prince Charles Hospital. He noted that even patients referred for routine scans are now seen within six weeks, and the majority within four weeks, of referral. The Ombudsman made two recommendations aimed at improving the radiology service further, and also recommended that Cwm Taf Health Board (as successor to the previous Cwm Taf NHS Trust) should formally apologise to Mrs D for the delays her husband experienced.

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